State of Oregon Department of Human Services

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State of Oregon

Department of Human Services

In the matter of Claimant
{Claimant Name}

{Street Address & Apt #}

{City, State, Zip Code}

Notice of Withdrawal

of Notice and Decision
DHS Case No. {Enter DHS Case Number}
OAH Case Number if applicable

Findings of Fact
1. The Department issued a notice and decision on {Date of Notice}, and properly served it on the claimant. The Department received the claimant’s Administrative Hearing Request on {Date of Request}.
2. Upon further consideration of the record, the Department is withdrawing the notice and decision, and is not taking the action proposed on the effective date originally indicated.
Conclusions of Law
1. If the Department issues a new notice and decision in the next 30 days, the Department will not require the claimant to re-file a request for an administrative hearing.
2. If the Department issues a new notice and decision after 30 days, the claimant will be entitled to request an administrative hearing.


The notice and decision of {Date of Notice} is withdrawn.


name and title of authorized employee,

Department of Human Services

{Street Address}

{City, State, Zip Code}
{Date Mailed}

Reconsideration or Rehearing: You may ask the Department of Human Services to rehear or reconsider this Order. A request for rehearing or reconsideration must be received by the hearing representative at the address below and postmarked no later than sixty (60) days from the date of service of this Order.
Certificate of Service: I certify that on {Actual Date of Mailing}, I mailed in a sealed envelope a true copy of this document, by first-class mail with sufficient postage, addressed to the claimant at the above-listed address. If this matter has been previously referred to the Office of Administrative Hearings, I have sent them a copy of this document.

{Name of DHS Employee}

{Title or Classification of DHS Employee}

{Street Address}

{City, State, Zip Code}

DHS 1117cwr (09/09)

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